| A. Credentialing Process. Each physician and Advanced Practice Professional (APP) shall be credentialed by the hospital for the appropriate specialty, including trauma care. |
E |
E |
E |
E |
E |
| B. Delineation or Reevaluation of Privileges: |
E |
E |
E |
E |
NA |
| (1) The trauma physicians and APPs shall be limited to those with demonstrated skills, commitment, experiences, and interest in trauma care. |
E |
E |
E |
E |
NA |
| (2) The trauma medical director shall serve on the medical staff as the trauma chief of service. |
E |
E |
E |
E |
NA |
| (3) Appointment and reappointment to the trauma admitting or consulting staff shall be coordinated by the trauma medical director and based on the following criteria: |
E |
E |
E |
E |
NA |
| (a) Maintenance of good standing in the primary specialty; |
E |
E |
E |
E |
NA |
| (b) Evidence of the required continuing medical education in trauma, including: |
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| (i) For general surgeons taking trauma calls evidence of 16 hours of trauma-related CME credits a year; |
E |
E |
E |
E |
NA |
| (ii) Over a 2-year period, half of the CME hours shall be obtained outside the hospital and be recognized by a national accrediting body; |
E |
E |
D |
D |
NA |
| (iii) ATLSTM which may be counted in required CME credits; and |
E |
E |
E |
E |
NA |
| (iv) Physician CME credits shall be documented in accordance with hospital policy. |
E |
E |
E |
E |
NA |
| (c) Documented attendance at Trauma QM meetings, as those meetings are institutionally defined, of no less than monthly averaged over 12 months; |
E |
NA |
NA |
NA |
NA |
| (d) Documented attendance at Trauma multidisciplinary meetings, Morbidity and Mortality (MandM) rounds, or hospital peer-review conference that deal with the care of injured patients; and |
NA |
E |
E |
E |
NA |
| (e) Satisfactory performance in managing trauma patients based on performance assessment and outcome analysis. |
E |
E |
E |
E |
NA |